Provider Demographics
NPI:1568893907
Name:FITZGERALD, KYLE (P A)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10512 S GLENSTONE PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2966
Mailing Address - Country:US
Mailing Address - Phone:225-757-6555
Mailing Address - Fax:225-757-6179
Practice Address - Street 1:10512 S GLENSTONE PL
Practice Address - Street 2:SUITE 102
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2966
Practice Address - Country:US
Practice Address - Phone:225-757-6555
Practice Address - Fax:225-757-6179
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2355007Medicaid
LA334144YNB7OtherMEDICARE PTAN